Thoughts on "planned home births are associated with double to triple the risk of infant death than are planned hospital births." - Page 5 - Mothering Forums

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#121 of 394 Old 03-17-2013, 06:04 AM
 
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The document really doesn't provide sources- and that is frustrating.

One can make an assumption that the data was collected from the Oregon Vital Statistics office. We're left to make some assumptions about the .6/1000 hospital rate - because that must exclude many higher risk births.

 

http://public.health.oregon.gov/HealthyPeopleFamilies/DataReports/PerinatalDataBook/Documents/pnch2/neonatalmortality.pdf

 

This document states that OR on a whole has a lower average neonatal mortality rate than the rest of the US. But this number is reported to be 3.8/1000.

 

More detail would be helpful in understanding how those numbers were generated. I agree.

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#122 of 394 Old 03-17-2013, 06:28 AM
 
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IdentityCrisisMama: I can send you the entire 3 page pdf, but she does not have the sources listed. I am in contact with her and can ask if she can provide the raw data or the sources.

 

There are quite a few people who don't like her conclusions or testimony, and are trying to pick it apart. Knowing Judith, I doubt that she missed anything. She is very thorough. I am thinking that she was not pleased with what she found either. She is a huge proponent of midwifery and even says that Oregon needs more DEMs, but that their educational standards, knowledge, and skills need to improve.

 

This is the same thing that has come up in multiple posts throughout this thread. Midwives who are losing babies are those who lack the education, knowledge, skills, and judgement. Home birth is safe, but it is the provider who makes it safe. If she is lacking, care will suffer, and mothers and babies will continue to lose their lives.
 


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#123 of 394 Old 03-17-2013, 06:38 AM
 
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I have posted a note to Ms. Rooks asking if she could supply the source of the material, and the data collection method. I will let you all know when I hear back from her.
 


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#124 of 394 Old 03-17-2013, 06:39 AM
 
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IdentityCrisisMama: I can send you the entire 3 page pdf, but she does not have the sources listed. I am in contact with her and can ask if she can provide the raw data or the sources.

 

There are quite a few people who don't like her conclusions or testimony, and are trying to pick it apart. Knowing Judith, I doubt that she missed anything. She is very thorough. I am thinking that she was not pleased with what she found either. She is a huge proponent of midwifery and even says that Oregon needs more DEMs, but that their educational standards, knowledge, and skills need to improve.

 

This is the same thing that has come up in multiple posts throughout this thread. Midwives who are losing babies are those who lack the education, knowledge, skills, and judgement. Home birth is safe, but it is the provider who makes it safe. If she is lacking, care will suffer, and mothers and babies will continue to lose their lives.
 

To be clear, I have no problem with her letter or her conclusions and do not wish to pick her apart at all - other than to wonder why she didn't cite sources in her testimony/letter. But I do I wonder how compelling her testimony will be without it. For the record, I think I'm probably fairly conservative when it comes to homebirth advocacy. So, while I sympathize with some of the questions and concerns of those on the more radical end of the spectrum, I tend to agree with Judith's testimony. My point is that we're talking about her testimony and the data she included...it's not picking her apart to wonder where that comes from or how that fits into the bigger picture. 


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#125 of 394 Old 03-17-2013, 06:57 AM
 
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If I remember things correctly I think Ms. Rooks was appointed to this task after the baby's death in  2011 when MANA would not release the data that Oregon requested regarding midwives and newborn deaths in that state. The state decided they needed answers and since Ms. Rooks is a CDC trained epidemiologist and a home birth/midwifery supporter she seemed like a good fit. She had no axe to grind and had a good understanding of the issues involved.

 

BTW: thank you for removing the troll posts. This conversation has remained quite civil and hopefully informative. I was worried it was about to veer off track with those odd postings.


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#126 of 394 Old 03-17-2013, 12:05 PM
 
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Posted in error, sorry.


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#127 of 394 Old 03-17-2013, 01:02 PM
 
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She does list her source the birth certificate data---


Twins do represent a clear bit of info and should be removed from the Oregon data when being compared because they surely are removed from the hosptial data- the medical policies on twins is deliver them at 34 weeks...just because they are twins nothing has to be in essence wrong- and because of being born early have a higher chance of dying ..

And this is a 1 year review analysis not really a study- to be clear about that you cannot tell if this is a fluke high or what occurs all the time.

And NOTE she is saying that there is a need for more DEMs , she is advocating for licensure only not for banning home birth.

I would say having lived in Washington state, near to Oregon when it was not a CPM state but had a self crediental that required students to attend 100 births as primary and had other very strict requirements this was not for licensing this is what the midwives organized for their own support and regulation- my impression is that now mostly licensed midwives belong to OMC and that the older more skilled ones still get together for peer review but many are retiring, and because of the liberal views on birth attendants license or no that many midwives have moved there from all over the country who would not follow rules and restrictions in their home states... So there just may be a very renegade crew there now. I too would like to see the stats on seasoned midwives... Mabye even an evaluation of best practices by midwives in general, who knows it may be the younger midwives that have better stats because they transfer sooner, or use dopplers or??? Having lived near there and having my own personal interaction with A midwife who I felt was highly unethical - i could be emotionally swayed to try and blast it all, but i am not going to be stampeeded-
I would also say BUYER beware, a midwife who will agree to do anything or everything at home, no matter what your primary health risks are is probably too good to be true- agreeing to not monitor a baby is not a reasonable agreement either unless you know you are having a stillbirth. continous EMF has not shown to be best but not listening at all is not best either.
The info Judith collected and much more is the kind of info we midwives should be collecting and evaluating ourselves- not waiting for someone else to roll it out of us but taking our stats and evaluating stuff- collectively and timely. Peer review is fine and well and can be timely but is limited to a single situation at a time, how do we do this without becomeing industrialized and too distant from our moms and yet be effective and safe. I have my own pet interests and that I would like to see and that is collecting the numbers on vitamin K administration and on vitamin K related bleeds within the first 6 months after birth but not only bleeds are there any other differences, is there a benefit to not getting vitamin K...
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#128 of 394 Old 03-17-2013, 01:17 PM
 
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So 12 hrs of clinicals in a week sure , students I have worked with could easily get that and if attending births would surpass that in 1-2 months.
Didnt the Yale program when starting out have an 18 month midwife certification, for non- nurses?
So if we were to strip out the " higher learning" and had a direct entry / vocational tech education it could be done in the 3 year schools- remember that the schools are mainly didatic. the majority of the clinical education is seperate from the school instruction.
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#129 of 394 Old 03-17-2013, 01:28 PM
 
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Anything beyond a high school diploma is "higher learning". There is a community college that offers a 2 year midwifery degree. I think it's in Wisconsin.

For anyone who wants to be a Certified Midwife (CM) taking the AMCB national exam, they can complete an 18 month or 2 year program, but those admitted to these program are required to have a Bachelor's degree in a related field or to have other knowledge in health care, such as Paramedics. I will try to find the details on those programs, but I'm sure it's on ACNM's site or on AMCB.

For each of those programs, clinical is integrated into the program, just as it is with other CNM program, campus based or distance learning such as CNEP.


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#130 of 394 Old 03-17-2013, 02:03 PM
 
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And this is a 1 year review analysis not really a study- to be clear about that you cannot tell if this is a fluke high or what occurs all the time.

And NOTE she is saying that there is a need for more DEMs , she is advocating for licensure only not for banning home birth.
 

nod.gif

 

So did she make that graph? From data she collected herself? I'm still a bit confused on the source...


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#131 of 394 Old 03-17-2013, 08:02 PM
 
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mwherbs -- as the mother of twins, and as someone who knows a fair number of twins, I can absolutely and completely assure you there is no medical policy requiring or even suggesting as a good idea delivering twins at 34 weeks as a matter of course.  I carried mine until 37 weeks 5 days.

 

If you are stating that this is ACOG policy or is otherwise endorsed by obstetric professional associations could you please provide a link?
 


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#132 of 394 Old 03-17-2013, 08:05 PM
 
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I know many mothers of twins. Excluding those who developed complications or PTL, I do not know any who were electively delivered at 34 weeks. The earliest I know of was 36. Most are 37-38 for those OBs who believe twins should be delivered slightly earlier than singletons.

Triplets typically go earlier, but this is due to the higher rate of complications.

DD 01/2007, DS 09/2011

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#133 of 394 Old 03-17-2013, 08:12 PM
 
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"So if we were to strip out the " higher learning" and had a direct entry / vocational tech education it could be done in the 3 year schools- remember that the schools are mainly didatic. the majority of the clinical education is seperate from the school instruction"

 

You know, barriers to entry are not always a bad thing especially when a job has a high level of responsibility, carries tremendous potential consequences and requires a lot of continuing education/continuing experience to keep skill sets up.  I do have serious questions about the safety of "hobbyist" midwives.

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#134 of 394 Old 03-17-2013, 08:14 PM
 
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"Most are 37-38 for those OBs who believe twins should be delivered slightly earlier than singletons."

 

Which is due to the increasing risk of stillbirth for twins as they move towards 40 weeks.  Later ain't always better.


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#135 of 394 Old 03-17-2013, 11:24 PM
 
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Except that the countries that we point to having lower mortality all along for the last 100 years have been midwife countries with direct entry/ vocational pathways to being a midwife- the out of country midwives I have met for the most part have alot of physical sensibilities ? CNM midwifery is becoming a Doctorate crediental very soon... Do we really believe that it takes a doctorate level education to be a midwife?
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#136 of 394 Old 03-17-2013, 11:44 PM
 
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Here is one article on the subject- i have to say that because of the concern of unknow cause of stillbirth that what I have seen is pretty much standard c-section delivery offered/ done at 34 weeks . http://www.obgynnews.com/index.php?id=11370&type=98&tx_ttnews%5Btt_news%5D=135891&cHash=da03e20e36
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#137 of 394 Old 03-18-2013, 12:50 AM
 
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I looked at the wonder pages to narrow down mortality rates of twins GA born Method of delivery , So western region 07-08 no twin births reported past 37 weeks. The greatest number of births were between 34-36 weeks and a very high death rate for twins over all- total twin births Oregon that year was between 450 and 500 births and the infant mortality rate was 47 / 1000
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#138 of 394 Old 03-18-2013, 01:42 AM
 
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mwherbs, that article is referring to monoamniotic twins being delivered by c section at 34 weeks.  Monoamniotic twins make up less than 1% of all twins, so unlikely to have any effect on the homebirth statistics.
 

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#139 of 394 Old 03-18-2013, 04:08 AM
 
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Here is one article on the subject- i have to say that because of the concern of unknow cause of stillbirth that what I have seen is pretty much standard c-section delivery offered/ done at 34 weeks . http://www.obgynnews.com/index.php?id=11370&type=98&tx_ttnews%5Btt_news%5D=135891&cHash=da03e20e36

That article recommends delivery between 34-37 weeks for monochorionic twins, not for all twins. There's a difference between monochorionic and dichorionic. And also a big difference between 34 weeks and 37 weeks. It would be more accurate to say that 34 weeks is the *earliest* that author recommends delivery for monochorionic twins in the absence of complications (or 32 weeks if they are also monoamniotic). Since this is a thread about homebirth, I think the salient question is which hospital data is being used in the Oregon stats and if the twin gestations are included, what the date cutoff is.

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#140 of 394 Old 03-18-2013, 07:13 AM
 
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There are so many posts on this thread and the topic has seemed to stray a bit.  I haven't seen anyone mention The Farm.  Impeccable, thorough home birth statistics.  These discussions often drive me insane.  We can not compare PLANNED home birth, to those born unplanned; in taxi cabs, on streets, premature, drug addicted, poverty stricken, and unwanted.  Why is it considered a home birth when the prom queen gives birth in the bathroom and tries to flush the baby down the toilet or wraps it in a towel and puts it in the garbage.  This entire study is so flawed.  Planned  babies, born via planned home birth, with skilled attendants = have far better outcomes, as do their mothers than any hospital birth.

 

http://www.thefarmmidwives.org/

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#141 of 394 Old 03-18-2013, 08:37 AM
 
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There are so many posts on this thread and the topic has seemed to stray a bit.  I haven't seen anyone mention The Farm.  Impeccable, thorough home birth statistics.  These discussions often drive me insane.  We can not compare PLANNED home birth, to those born unplanned; in taxi cabs, on streets, premature, drug addicted, poverty stricken, and unwanted.  Why is it considered a home birth when the prom queen gives birth in the bathroom and tries to flush the baby down the toilet or wraps it in a towel and puts it in the garbage.  This entire study is so flawed.  Planned  babies, born via planned home birth, with skilled attendants = have far better outcomes, as do their mothers than any hospital birth.

 

http://www.thefarmmidwives.org/

Which study are you referring to? If it's the Wax study, we already know that. If it's the Oregon testimony, I am still waiting to hear from Ms. Rooks about the data collection and methods. So, we don't have quite enough information yet to saw that one is flawed.

One of the first things we learn about research is that the results apply only to the population involved in the study. You can't take those results and extrapolate them to another midwife, country or community without also replicating all the variables involved. What this means is that if you want to use the Farm midwives' stats to prove safety of OOH birth, then you need to also use their protocol for risking  clients out, you need to have their educational background, the same emergency care needs to be in place. You would also need to replicate the community, their educational background, their diet , lifestyle, and work habits, as well as the community support. 

If any of those things are not exactly the same , then you can't use their numbers to prove that birth is the same just because it is not in hospital. 


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#142 of 394 Old 03-18-2013, 08:52 AM
 
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Midwife Wanda -- did you miss the part in the materials which specifically pulls out the DEM numbers for Oregon midwives?   Planned homebirths attended by Oregon DEMs is what is being analyzed here.

 

Perhaps less bluster and more analysis is called for here. 

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#143 of 394 Old 03-18-2013, 08:53 AM
 
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Rooks makes it clear in her testimony that the data is from planned OOH births.

 

"In 2011 the Oregon House Health Care Committee amended the direct-entry midwifery

—“DEM”—law to require collection of information on planned place of birth and planned birth attendant on fetal -death and live- birth certificates starting in 2012.

 

Oregon now has the most complete, accurate data of any US state on outcomes of births planned to occur in the mother’s home or an out-of-hospital birth center.

 

This table summarizes that data (PTT slide):"

 

Emphasis hers.

 

 https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

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#144 of 394 Old 03-18-2013, 10:56 AM
 
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When i lived near Oregon one spiritual midwife I knew, only prayed at births-, she would go to the health department and would report the births using the midwife designation, i would guess that even if the laws in Oregon changed to require a license they would not be able to stop her and others like her from attending births.
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#145 of 394 Old 03-18-2013, 11:28 AM
 
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The link emphasizes that this is an analysis of planned homebirths/birth center births and is focused solely on the outcome for term births.

 

What the materials demonstrate very clearly is just how good hospital mortality rates are for term infants.  Also, I find it interesting that she did not specifically call out a line in the table for CNM births.  You can get there simply by subtracting the DEM attended birth information from all the planned homebirth/birth center birth information.

 

When I do that, I get 2 deaths for CNMS out of between 600 and 700 births attended. 

Thanks!

This thread is moving so fast I can't keep up. ;)

 

I am certainly willing to be open-minded, but when all of a sudden one study/review seems to show results that are radically different from what we've seen before, I think it's prudent to ask why.  And when *any* studies are concerned, we have to make sure we're comparing apples to apples (as much as possible). Even if that doesn't change the results, it may change the practical ways those results are applied.  Hence my desire for clarification. :)

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#146 of 394 Old 03-18-2013, 12:11 PM
 
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Here is the reply from Judith Rooks about the testimony she gave and the background. She thinks this should answer any questions, but said she would be happy to answer anything else that comes up. I think this is an especially important point:  neonatal deaths that occur in hospitals after in-labor transfers from OOH settings are no longer attributed to the hospital but are appropriately attributed to the planned OOH birth site.

 


Conversation: Oregon testimony
Subject: Re: Oregon testimony

In 2011 the Oregon Legislature amended the law for licensing and regulating direct-entry midwives (DEMs) in several ways and mandated that information on planned place-of-birth and birth attendant be collected on term fetal death and live birth certificates, allowing creation of data on fetal and neonatal deaths associated with term births in Oregon according to where they were planned to occur.  The data exclude deaths caused by prematurity.  In addition,  neonatal deaths that occur in hospitals after in-labor transfers from OOH settings are no longer attributed to the hospital but are appropriately attributed to the planned OOH birth site.

Oregon now has better data than any other state on OOH birth outcomes, but it is not perfect.  The biggest problem relates to the fetal death component of the data on term births planned.  Fetal deaths (also called stillbirths) can occur antepartum (before labor) or intrapartum (IP, during labor).  Antepartum fetal deaths are much more common than IP fetal deaths.  Extremely few term IP fetal deaths occur in hospitals.  Most fetuses in severe distress are diagnosed by electronic fetal monitoring and delivered by cesarean section.  This saves some babies, while others may die later and be counted as neonatal deaths.  

The big problem now is the data on deaths of term fetuses during births planned to occur in hospitals.  The vital statistics data show 59 fetal demises associated with 39,984 term births planned to occur in Oregon hospitals in 2012, a rate of 1.5/1000 births.  I can’t use those data because the vital statistics system doesn’t distinguish between IP fetal deaths during labor and planned in-hospital deliveries of term fetuses that were known to be dead before the woman went into labor.   Women carrying known-to-be-dead fetuses are commonly admitted to hospitals for induction of labor to get the dead baby delivered as soon as possible in order to protect the mother from hemorrhage caused by disseminated intravascular coagulation (DIC).   I can’t use comparison data that I know to be misleading.  I am trying to figure out how to deal with that problem in the  most truthful way.

I also need a little more information on one of the deaths associated with a birth attended by a “lay midwife” (as per the record).  When I have more information on that case, I will revise the table.  I anticipate that the total (IP fetal + NN) mortality rate for planned OOH births attended by direct-entry midwives will be about 6 times higher than the rate for planned term births in hospitals, or higher.  One of the deaths associated with births attended by DEMs was due at least in part to congenital anomalies.  I calculated the rate both with and without that death but used the lower rate (excluding the death associated with congenital anomalies) when comparing the OOH total mortality rate with the rate for births planned to occur in hospitals, even though the data on planned in-hospital births includes babies with congenital anomalies.

Judith Rooks

 

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#147 of 394 Old 03-18-2013, 12:32 PM
 
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Then there are the things that midwives do in the name of "helping the labor along" like giving cytotec or pitocin, in some cases without informing the laboring woman.  All of these were things the midwife thought she could handle at home rather than transferring the woman or her baby to the hospital. If you don't think these things happen, all you need to do is a google search and the women's stories will show up, a lot of them.

 

jaw.gif I must have missed this earlier. They are giving cytotec at home? I had it written in to my hospital birth plan that was in my files that I DO NOT CONSENT to the use of cytotec. I never imagined that that would be something I would have to worry about with choosing a home birth midwife. 


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#148 of 394 Old 03-18-2013, 12:46 PM
 
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It isn't just Dr. Amy's site where you can find these. The moms are writing these stories on their blog posts, in baby center,and other places. There are a lot of them. I finally had to quit reading the stories fruitfulmomma.

 

I have first hand knowledge of a midwife who told the mom she was going to just massage arnica oil into a swollen cervix. She did that, but had also crushed up a cytotec tablet and massaged that in at the same time. She was rather proud of herself when the mom went from a very stuck 6 cms to complete. Not so much so when the baby died after an 8 minute shoulder dystocia.

Yes, you would think that home birth midwives would all be sticking to the same criteria to risk women out, to transfer moms and babies, etc., but very sadly, even though they say they will do these things, some of them don't. Moms and babies die because of it.

 

The standard should be "no identifiable risk factors" during pregnancy, labor, birth, and for the newborn.
 

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#149 of 394 Old 03-18-2013, 04:07 PM
 
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erigeron: breech should also be considered a high risk condition. It is one of the conditions that Oregon is considering restricting for home birth midwives. (See the first link in my post above)

 

The problem with restricting breech at home is that many hospitals don't allow breech birth, which forces women into unwanted C-sections. If women could have their breech baby vaginally in the hospital, probably most of them wouldn't be doing it at home.

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the medical policies on twins is deliver them at 34 weeks.

 

mwherbs, can you cite a source for that? Both of the twin births I attended as a doula were at 36 weeks, one induced because mom developed pre-eclampsia and one mom went into labor on her own.

 

 

Quote:
When i lived near Oregon one spiritual midwife I knew, only prayed at births-, she would go to the health department and would report the births using the midwife designation, i would guess that even if the laws in Oregon changed to require a license they would not be able to stop her and others like her from attending births.

 

I wish that those women wouldn't call themselves midwives. This was brought up at the healthcare committee hearing. If someone isn't working within the standards of care/scope of practice for a midwife, they should be using a different title.


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